An embarrassment to evidence-based medicine

A simple question asks what does a “routine physical” entail leads to an explosion of referrals and unnecessary test suggestions:

Q: What further referrals might be suggested?

A: Depending on your risk factors, a referral to a gastrointestinal specialist may be ordered for colon-rectal cancer screening, a referral to a cardiologist for heart disease screening, an eye doctor to evaluate for glaucoma, a diabetes doctor for evaluation of high blood sugar, a referral to a gynecologist for a pap smear, mammogram or hormone therapy, and referral to orthopedic for evaluation of bone problems.

Q: What further diagnostic test may be recommended?

A: Depending on each person, the following may be ordered: chest X-ray, blood test to evaluate for anemia, electrolytes, cholesterol, diabetes, liver tests, stress test, bone density and prostate test.

Let me go through these suggestions – I previously wrote about unnecessary testing a few weeks ago.

colon cancer screening: agreed
heart disease screening: not routinely recommended
diabetes screening: agreed
Pap smear/mammogram: agreed
“hormone therapy”: uh, not after the recent results of the WHI study
CXR: not routinely recommended
anemia: not routinely recommended
electrolytes: not routinely recommended
cholesterol: agreed
liver tests: not routinely recommended
stress test: not routinely recommended
bone density: agreed
prostate test: agreed

I’m pretty sure this doctor has never heard of the USPSTF and simply perpetuates the common notion that “more medicine is better medicine”. It’s physicians like Dr. Sangani who sink evidence-based medicine today.

A reader appropriately pointed out the prostate cancer screening is a class C USPSTF recommendation. That’s true, so I’ll amend my comments:

“prostate test: agreed, after discussion of the pros and cons with the patient”

Apologies. My mind reflexively thinks back to the Merenstein prostate cancer screening malpractice case whenever I discuss PSAs.

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  • Anonymous

    A primary care physician that doesn’t know how to screen for heart disease, perform a pap smear, order a mammogram, evaluate the appropriateness of hormone therapy, nor evaluate high blood sugar!

    No wonder primary care medicine is dying, Maybe it should.

  • SarahW

    Most women appreciate hormone therapy for menopause, even if for limited duration. And the negative health effects don’t apply to women who can avoid premarin.

  • Hormones not just for menopause

    Hormone therapy technically includes men and women who take thyroid hormone or androgens and estrogens for other therapeutic purposes. I’d sure want an endocrinologist monitoring my thryroid function.

  • Michael Rack, MD

    “I’d sure want an endocrinologist monitoring my thryroid function.”
    Thyroid function monitoring can usually easily be done by a primary care physician.

  • Anonymous

    prostate test: agreed
    Hello? USPSTF doesn’t recommend either for- or against- prostate testing. Kevin, you mentioned zillion times on this blog that you guys mostly do it for legal reasons and that there is 0 evidence that it does any good. You sure are consistent.

    And the negative health effects don’t apply to women who can avoid premarin.
    There is no evidence that the type of HRT makes any difference. WHI only included premarin and provera, but there is no reason to think other hormones are safer.

    Also, the person who sent the letter in the referenced article is 65 – long past menopause. There is no reason for a 65-year old to be on HRT unless it is a ultra-low-dose estrogen patch for osteoporosis or she has so severe hot flushes she cannot function without it. Certainly not something a symptomless 65-year old should go to a doctor for.

    BTW – I am on HRT myself, but I have POF and am not yet 50. So I can say WHI doesn’t apply to me since it included 0 women with POF, nor compared our risks to those of women who our age who still have normal periods.

  • Function that.

    I wouldn’t. Thyroid hormone monitoring is more than checking TSH, T4, T3. It’s evaluating the whole patient, being aware of subtle signs of trouble with heart, bones, etc.. in many cases keeping an eye on a wonky thyroid that may need ultrasound, biopsy, surgical removal, etx..being on top of situations that change the need for hormones and will probably require adjustment…its so much more than just giving out a standard dose of meds.

    I frankly don’t think time-pressed FMP are up to the task. They are good screeners and pointers. It’s better to have a complex medical situation followed by someone who is up on the finer points and doesn’t get agitated having to deal with special problems, therefore conveniently avoiding seeing them.

  • Kevin

    Anon 12:31,
    You’re right. Prostate screening is a class C recommendation. I keep thinking back to Merenstein’s case where he got sued for not screening.

    So, I’ll amend my response to: “Agreed, after discussion of the pros and cons with the patient.”

    Thanks for pointing that out.


  • Anonymous

    I assume “FMP” means Family Medical Doctor.

    If the sole purpose of an “FMP” is to be “good screeners and pointers” then Nurse Practitioners in a minute clinic in
    Wallmart is all that is needed.

  • Anonymous

    Anon 1:29 – Family practitioners are a step above that. They are better at screening and pointing than nurses, any day. Plus, they know what they don’t know. However, they are not really who I would turn to to manage complex hormone therapy.

  • Anonymous

    “Plus they know what they don’t know”


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